Page 39 - Drug Class Review

Final Report Update 1 Drug Effectiveness Review Project

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and tacrine, 28%. Similarly, the relative proportions of patients who experienced vomiting were 5%,
21% and 28%, respectively; diarrhea occurred in 10%, 16% and 16%, respectively. Another review

reported a loss of body weight of 0.5 to 2.5 kilogram for galantamine at doses of 16mg/day to 32mg/day
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and a loss of body weight of 1.39 to 1.78 kilogram for rivastigmine at doses of 6 mg/day to 12 mg/day.

Data from the Réseau sur la Maladie d’Alzheimer Francais (REAL.FR) cohort was used to assess the risk
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of weight loss with AChEI. This long-term observational study found the risk of clinically significant
weight loss to be similar for Alzheimer’s patients taking AChEIs and patients not taking these drugs
(21.1% vs 19.5%, respectively; P = 0.81). However, we excluded this study for reasons of quality because
we were unable to assess the similarity or differences between the two populations, and little information

was provided with regard to the type, intensity, or duration of drug treatment.

Cardiovascular adverse events

Bradycardia and subsequent dizziness or syncope originates from central and peripheral muscarinic
cholinergic stimulation. Cardiovascular adverse events can lead to falls and other types of injury-causing

accidents. We did not find any trials directly comparing the incidence of cardiovascular adverse events
among ChEIs and memantine.

Cardiovascular adverse events may be of particular concern in patients with cardiac conduction disorders
or a sick sinus syndrome. One head-to-head study reports no statistically significant differences in
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changes of heart rates between donepezil and galantamine. Two open-label comparative trials reported
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no difference in cardiovascular events between donepezil and galantamine and rivastigmine. Most
placebo-controlled trials revealed no other significant differences in cardiovascular events, vital signs, or
electrocardiogram (ECG) findings. One trial described a statistically significantly larger reduction of heart
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rate in patients treated with donepezil than in those given placebo. However, the incidence of
bradycardia (heart rate < 50 beats per minute) was not significantly different among treatment groups. An

analysis of prescription-event monitoring (n = 1,762) in general practice in the UK did not find evidence
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for cardiac arrhythmias with donepezil treatment.

One pooled data-analysis of RCTs including 2,791 patients evaluated ECG results from four clinical trials
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of rivastigmine; rivastigmine had no apparent effect on heart rate. However, patients with underlying
ECG abnormalities did not meet eligibility criteria of the RCTs.

Alzheimer's Drugs Page 39 of 205